What is the treatment for ileocecal intussusception?

Ileocecal Intussusception: Clinical Case Report Framework

Clinical Presentation

Adult ileocecal intussusception typically presents with chronic, intermittent abdominal symptoms rather than acute obstruction, making diagnosis challenging. 1, 2

Typical Symptom Pattern

• Crescendo abdominal pain over days to weeks, often with prior similar episodes that resolved spontaneously 1
• Intermittent cramping lower abdominal pain with nausea and vomiting 2
• Chronic nonspecific symptoms including weight loss, changes in bowel habits (intermittent diarrhea), and gastrointestinal bleeding 3
• Abdominal distention in cases progressing to acute mechanical intestinal obstruction 4, 2

Critical Diagnostic Consideration

In 86-93% of adult cases, an underlying pathologic lesion exists—most commonly malignancy (adenocarcinoma), followed by inflammatory bowel disease, adhesions, or benign tumors. 5, 6 This contrasts sharply with pediatric intussusception, which is typically idiopathic. 6

Diagnostic Workup

Imaging Modalities

• CT scan is the imaging modality of choice to confirm diagnosis and identify complications in hemodynamically stable adults 5
• Abdominal ultrasound can reveal the characteristic appearance of intussusception 1
• Colonoscopy is essential to visualize the lead point pathology and obtain tissue diagnosis 1, 4

Key Assessment Points

• Evaluate for peritonitis, strangulation, or bowel ischemia requiring immediate surgery 5
• Assess hemodynamic stability to determine intervention urgency 5
• Rule out perforation (pneumoperitoneum on imaging) which mandates immediate surgery 7

Treatment Approach

Surgical Management (Standard of Care)

Formal surgical exploration with bowel resection following oncological principles is recommended due to the high malignancy risk in adults. 5, 6

Surgical Technique

• Begin exploration from the ileocecal junction (distal to obstruction) where bowel is less dilated and safer to handle 5
• Assess intestinal viability—if ischemia is present, perform surgical resection 5
• Resection of the affected segment is recommended as it results in fewer recurrences compared to simple reduction 8, 5
• Use indocyanine green (ICG) fluorescence angiography to guide resection margins when intestinal perfusion is questionable 5
• Close all mesenteric defects with non-absorbable sutures after reduction to prevent recurrence 5

Timing Considerations

The 48-hour threshold is critical—mortality increases significantly with delayed intervention. 5, 7 In stable patients with persistent abdominal pain and inconclusive findings, exploratory laparoscopy is mandatory within 12-24 hours. 5

Non-Operative Management (Highly Selective)

Non-operative management may be attempted only when the patient is hemodynamically stable, has no signs of peritonitis or bowel compromise, and has a colonic location amenable to colonoscopic reduction. 5

Endoscopic Approach

• Endoscopic pneumatic reduction followed by colonoscopic resection of the lead point (e.g., lipoma) can be utilized safely when malignancy is ruled out 4
• Endoscopic reduction carries high recurrence rates and is not standard practice 5, 7
• Mandatory close monitoring for at least 24 hours after reduction is necessary to detect early recurrence 5, 7
• Surgical consultation must be obtained in all cases, even when attempting non-operative management 5

Absolute Contraindications to Non-Operative Management

• Signs of peritonitis (guarding, rigidity, rebound tenderness) 7
• Hemodynamic instability despite resuscitation 7
• Radiological evidence of perforation 7
• Clinical signs of bowel ischemia (markedly elevated lactate, severe continuous pain, bloody stools) 7

Representative Case Examples

Case 1: Malignant Lead Point

A 56-year-old male with 2 years of intermittent abdominal pain episodes presented with crescendo pain over 2 weeks. Ultrasound revealed ileocecal intussusception. Colonoscopy showed a tubulovillous adenomatous polyp with high-grade dysplasia, but right hemicolectomy revealed underlying cecal adenocarcinoma. 1

Case 2: Benign Lead Point with Endoscopic Management

A 58-year-old male with acute mechanical intestinal obstruction from ileocecal intussusception due to ileal lipoma. After endoscopic pneumatic reduction, the lipoma was resected colonoscopically without complications. 4

Case 3: Post-Surgical Adhesion

A 21-year-old female with diffuse cramping abdominal pain and distention. Workup revealed ileocecal intussusception with a prior appendectomy scar serving as the lead point, discovered during exploratory laparotomy. 2

Case 4: Colon Carcinoma Presentation

A 64-year-old female with weight loss, intermittent diarrhea, and transrectal bleeding. CT scan showed neoproliferative appearance with intussusception of ascending colon. Right hemicolectomy confirmed colon adenocarcinoma. 3

Critical Pitfalls to Avoid

• Never assume idiopathic etiology in adults—underlying pathology exists in 86-93% of cases 5
• Do not delay surgery beyond 48 hours as mortality increases significantly 5, 7
• Do not attempt endoscopic reduction without ruling out malignancy and ensuring hemodynamic stability 5, 7
• Do not discharge patients immediately after successful reduction—24-hour monitoring is mandatory 5, 7